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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881148
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:16:30 PM

Document Has Been Signed on 11/07/2024 03:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LEVI HOMEFACILITY NUMBER:
331881148
ADMINISTRATOR/
DIRECTOR:
SANDRA HERNANDEZFACILITY TYPE:
735
ADDRESS:73463 GUADALUPE AVENUETELEPHONE:
(760) 600-7020
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY: 4CENSUS: 4DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Julie Baez- House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Debbie Palacios and Licensing Program Manager (LPM) Tricia Danielson made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with House Manager (HM) Julie Baez who was informed of the purpose of the visit. The facility has a fire clearance for two (2) ambulatory and two (2) Non-ambulatory clients and serves adults ages 18 through 59 years of age. Staff present have a criminal record clearance and are associated with the facility.

LPAs toured the facility and reviewed records. During the tour, LPAs observed the facility is made up of a one-story home with four (4) client bedrooms and one (1) office room and three (3) bathrooms, a living room, dining room, kitchen and backyard. All client bedrooms had the required furniture, lighting, and closet storage. LPAs toured the facility's exterior and observed outdoor pathways were free of obstructions. LPAs toured the kitchen and observed the facility has a two-day supply and perishable foods and more than a seven-day supply of non-perishable foods that were observed to be properly stored and readily available. Knives and sharp instruments were secured in a locked box in the staff office room. LPAs reviewed random client and staff records. Client files reviewed had updated Individual Program Plans and signed admission agreement. LPAs reviewed the physical medications and medication logs. LPAs also observed the facility has laundry area cabinet cleaning solutions, disinfectants, and laundry detergents. LPAs also observed additional clean towels, blankets, and linens for the clients stored in the hallway closet. During today's visit, LPAs did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Julie Baez.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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